Advice for Graduating Residents

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I am a 3rd year resident starting my first attending job in late July. I feel pretty comfortable overall in clinic and decision making. I’m still feel nervous about operating by myself. I do alright in the OR but it’s always been with an attending present. Also I think it will take awhile to get cases so I am sure I’ll feel rusty by the time I start operating.

I guess I’m just hoping to get any good advice and/or encouragement for those of us graduating and starting to practice soon.

 

[Feli]

You will do fine.
You are over-trained for the surgery part if you went to a half decent program.
If you are at a good program, you should have been operating essentially on your own for the whole third year - or longer (attending basically retracts for you, you teach juniors). Either way, you will do fine.

It SHOULD take awhile to get cases as an attending.
Do the amps or the fractures that come along on-call or ER f/u, but going slow in office is fine. It's smart.
Don't be those tools who are trying to talk every patient who smokes weed daily and lives alone in a 3rd story apartment into big elective recons.
I get those patients every week who some area DPM told needed XYZ big recon, and they clearly just want insoles/callus care or PT.
You will quickly learn that we have thousands of DPMs in our profession who undertrained and/or cut-happy. It's sad.
Doing too much surgery/procedures - esp in one session - just causes CRPS and bad problems - even if it's executed fair/good and it "heals."
There are many surgical cripples with bad neuritis or perma-edema even if the peroneal or cavus or pantalar or forefoot slam or whatever repair surgery was well done (tendon/osseous). Often, it's just way too much surgery (hint: zaftig ppl can't stay off the foot, have poor nutrition, and will have the most issues).
Further, your hospitals/ASC will begin to haaate docs who try long cases with suspect health pts. They do NOT want to do long general cases on diabetic bigguns. They want fast easy stuff and will think you're a star for those cases - while they draw straws for who has to scrub Dr. four-hour-revision-recons. And PS, PCPs also hate when they hear you are putting their patients on the table for hours and hours... it's a risk to them for doing H&P.

The best advice is just to pick your candidates well... get to know them a bit.
Figure out what they expect AND what they can reasonably recover from (health, social support, etc).
Do a few conservative/pre visits with any elective sx candidate, for many reasons: get to know them (build trust, which is very useful when - not if - you inevitably have complications or delay healing), document conservative (makes money and medicolegally protective), sniff out the crazies (often hard to detect at just first or 2nd visit), figure out if they make vs miss appts, fill their Rx or use DME advised or attend PT as you Rx, etc. If they are clearly a bad candidate or too sick or nutty, just make them insoles or send them to PT or bore them and let them be someone else's problem. I have told many patients, "you can find someone to do a surgery for you, but I will tell you : it won't be me."

In the OR, half the game is won before starting (boarding slip for OR, confirm implants/equipment with rep and staff, videos/anat reviewed, pt Rx and edu pre-op, etc).
Expect non-compliance even from the pts who seem fine. Over-fixate things, bi-valve cast your big recons/trauma (don't trust CAM boot until later), etc.
For trauma or infections, you obviously have little choice, but document fairly well, expect problems and keep f/u tight.

...Later on, once you're hopefully ABFAS BC and not employed, YOU can decide what you want to see or not see as your own boss.
You can punt types of cases/patients you just find to be PITA.
You will realize the big recons that are just not fun or profitable (per hour) to you and keep or punt them.
You can focus on the types of cases/clinic you want to focus on. Market how you want to market.
You can work the hours you want... and work with staff trained and supplies set how you want.
You can let the Charcot and wound slop and crazies and fat ppl and smokers be somebody else's problem.

Good luck at the new job, and it'll go well.

 

[air bud]

You will do fine.
You are over-trained for the surgery part if you went to a half decent program.
If you are at a good program, you should have been operating essentially on your own for the whole third year - or longer (attending basically retracts for you, you teach juniors). Either way, you will do fine.

It SHOULD take awhile to get cases as an attending.
Do the amps or the fractures that come along on-call or ER f/u, but going slow in office is fine. It's smart.
Don't be those tools who are trying to talk every patient who smokes weed daily and lives alone in a 3rd story apartment into big elective recons.
I get those patients every week who some area DPM told needed XYZ big recon, and they clearly just want insoles/callus care or PT.
You will quickly learn that we have thousands of DPMs in our profession who undertrained and/or cut-happy. It's sad.
Doing too much surgery/procedures - esp in one session - just causes CRPS and bad problems - even if it's executed fair/good and it "heals."
There are many surgical cripples with bad neuritis or perma-edema even if the peroneal or cavus or pantalar or forefoot slam or whatever repair surgery was well done (tendon/osseous). Often, it's just way too much surgery (hint: zaftig ppl can't stay off the foot, have poor nutrition, and will have the most issues).
Further, your hospitals/ASC will begin to haaate docs who try long cases with suspect health pts. They do NOT want to do long general cases on diabetic bigguns. They want fast easy stuff and will think you're a star for those cases - while they draw straws for who has to scrub Dr. four-hour-revision-recons. And PS, PCPs also hate when they hear you are putting their patients on the table for hours and hours... it's a risk to them for doing H&P.

The best advice is just to pick your candidates well... get to know them a bit.
Figure out what they expect AND what they can reasonably recover from (health, social support, etc).
Do a few conservative/pre visits with any elective sx candidate, for many reasons: get to know them (build trust, which is very useful when - not if - you have inevitably have complications or delay healing), document conservative (makes money and medicolegally protective), sniff out the crazies (often hard to detect at just first or 2nd visit), figure out if they make vs miss appts, fill their Rx or use DME advised or attend PT as you Rx, etc. If they are clearly a bad candidate or too sick or nutty, just make them insoles or send them to PT or bore them and let them be someone else's problem. I have told many patients, "you can find someone to do a surgery for you, but I will tell you : it won't be me."

In the OR, half the game is won before starting (boarding slip for OR, confirm implants/equipment with rep and staff, videos/anat reviewed, pt Rx and edu pre-op, etc).
Expect non-compliance even from the pts who seem fine. Over-fixate things, bi-valve cast your big recons/trauma (don't trust CAM boot until later), etc.
For trauma or infections, you obviously have little choice, but document fairly well, expect problems and keep f/u tight.

...Later on, once you're hopefully ABFAS BC and not employed, YOU can decide what you want to see or not see as your own boss.
You can punt types of cases/patients you just find to be PITA.
You will realize the big recons that are just not fun or profitable (per hour) to you and keep or punt them.
You can focus on the types of cases/clinic you want to focus on. Market how you want to market.
You can work the hours you want... and work with staff trained and supplies set how you want.
You can let the Charcot and wound slop and crazies and fat ppl and smokers be somebody else's problem.

Good luck at the new job, and it'll go well.

Sir I am a foot & ankle surgeon. I can cut therefore I will.

 

[air bud]

But also take what @Feli said as the truth. He knows what he is talking about about even if he rejects modern fixation techniques.

 

[Hybrocure]

I am a 3rd year resident starting my first attending job in late July. I feel pretty comfortable overall in clinic and decision making. I’m still feel nervous about operating by myself. I do alright in the OR but it’s always been with an attending present. Also I think it will take awhile to get cases so I am sure I’ll feel rusty by the time I start operating.

I guess I’m just hoping to get any good advice and/or encouragement for those of us graduating and starting to practice soon.

Exhaust conservative treatment before surgery. Don’t chase board numbers. Do what’s best for the patient. I have more patients seeking help for foot pain after bad surgeries than I do patients needing surgery who haven’t had surgery before. You’ll find there’s a graveyard of botched hammertoes and bunions walking into your clinic from our predecessors long gone. Many of whom are just there for nail care.


Such is the way of podiatry.


Foot surgery sucks recovery wise and most patients aren’t aware of it. We don’t follow this generally as residents. This will hit you hard like a sack of bricks if you start getting cut happy as new attending. The more I practice as an attending the less I am keen to operate compared to my mentality as a resident. That’s just me. There’s a lot of new grads out there busting out recons and fusions when they only ever retracted prior and that’s scary stuff to me. I don’t have the heart to do that to a person. Things you can’t do well, refer out.


If they aren’t in pain don’t operate as far as electives go. If it’s infection or osteo be aggressive because it’ll cause you trouble down the road if you aren’t.

This isn’t school, this isn’t residency. Check your ego at the door and do what’s best for patient care even if it means sending a patient down the road to a better surgeon

 

[shadesofgrey]

One thing I've come to appreciate is that you can talk most of your patients into or out of a surgery very easily. This is very powerful, use it smartly because if you talk them into it and there are complications they aren't happy. Every day I talk people out of surgery because they don't understand the postop course or what being off their feet does to the rest of their body. It should also be a red flag if you are struggling to talk someone out of surgery.

As others have mentioned, if you aren't able to do the procedure, send the patient down the road. It feels like admitting defeat at first, but I've had so many patients thank me for being honest and doing the right thing. Contrast this with doing the procedure and the stress/anxiety of the case and postop course. Now this doesn't mean you shouldn't push your skill boundaries. It just means you need to grow in safe and manageable intervals. You know your skills, would you feel comfortable having your family member being operated on by someone at your skill level.

 

[deleted285117]

Never do cosmetic surgery 🥸

 

[Feli]

...Foot surgery sucks recovery wise and most patients aren’t aware of it. We don’t follow this generally as residents. This will hit you hard like a sack of bricks if you start getting cut happy as new attending. The more I practice as an attending the less I am keen to operate compared to my mentality as a resident. That’s just me. There’s a lot of new grads out there busting out recons and fusions when they only ever retracted prior and that’s scary stuff to me. I don’t have the heart to do that to a person. Things you can’t do well, refer out...

Yes, this cannot be overstated.
Use handicap temp permits, DME, assist devices as well as possible.

You have to ascertain what recovery someone can reasonably do.
When the XR says triple but the patient age or health or BMI and ability to recover says injection and Arizona brace... do the latter.
When the XR says Lapidus + Weils and the patient is spouting off about the bunion they saw on IG that heals in about a week, punt them.
If the XR says first MPJ fusion but the issue is just dorsal ulcer and the patient is 88yo, do an exostectomy (or soft toe box shoes).
If the XR says calc ORIF or bimall ORIF and the patient is a malnourished tweaker without transportation, serial cast them.

The convalescence is real. There are plenty of people to do surgery for (and plenty of other DPMs who will cut on ones you pass on).
People absolutely do get DVTs, falls from the boot/cast, infections, CRPS, osteoporotic fractures after immobilization, and other issues.

Again, there is noooooooo shortage of DPMs who will do 8 Charcot surgeries or 4 nonunion retries or 3 consecutive first MPJ implants or various other goofball stuff. When those patients limp into your office, simply do as much nothing as possible: pain mgmt refer, pain crm, PT, brace, or maybe HWR as appropriate. It's sad, but you typically don't want to worsen the problem with more invasive stuff (revision, injects, etc).

 

[Hybrocure]

Yes, this cannot be overstated.
Use handicap temp permits, DME, assist devices as well as possible.

You have to ascertain what recovery someone can reasonably do.
When the XR says triple but the patient age or health or BMI and ability to recover says injection and Arizona brace... do the latter.
When the XR says Lapidus + Weils and the patient is spouting off about the bunion they saw on IG that heals in about a week, punt them.
If the XR says first MPJ fusion but the issue is just dorsal ulcer and the patient is 88yo, do an exostectomy (or soft toe box shoes).
If the XR says calc ORIF or bimall ORIF and the patient is a malnourished tweaker without transportation, serial cast them.

The convalescence is real. There are plenty of people to do surgery for (and plenty of other DPMs who will cut on ones you pass on).
People absolutely do get DVTs, falls from the boot/cast, infections, CRPS, osteoporotic fractures after immobilization, and other issues.

Again, there is noooooooo shortage of DPMs who will do 8 Charcot surgeries or 4 nonunion retries or 3 consecutive first MPJ implants or various other goofball stuff. When those patients limp into your office, simply do as much nothing as possible: pain mgmt refer, pain crm, brace, or maybe HWR as appropriate. It's sad, but you typically don't want to worsen the problem with more invasive stuff (revision, injects, etc).

Spot on. The problem is that we have a lot of binary thinkers in our field (honestly, medicine as a whole really) who base treatments off of books/boards vs reality. They focus on the X-ray and don’t read the patient. They’ll go through residency and it still won’t click.

In the past it was a money thing, these days I think it’s just trained into new grads to be electively aggressive.

 

[Adam Smasher]

Random bits and pieces:

Time management is key. Know when to tell someone "I have to get going." "I have someone waiting in the next room" etc

Pts will never complain to your face if you running late, but nothing pisses them off more.

Always ask permission before giving an injection, pts appreciate it even if they obviously need the injection.

Pay attention to co-pays. If the pt is medicare+secondary, this may just be a social call. But If someone needs to ante up $60 just to get past the front door, take their complaint seriously.

 

[eyeeye_captain]

Keep in touch with and bounce ideas off trusted mentors/colleagues/coresidents/classmates. If you’re waffling on what to do with a tough case, this will drop your blood pressure several points. It also keeps up active learning, can teach you some business stuff, and lets you vent when you inevitably pick up a disaster.

 

[HardRoadPaved]

Always ask permission before giving an injection

and this is why we have clipboard nurses.

 

[Adam Smasher]

What I am getting at is that when you ask the patient's permission before placing the injection, you acknowledge their agency in the decision-making surrounding their own health care and cultivate a doctor-patient relationship founded on a sense of mutual trust and partnership rather than paternalism.

 

[Hungry_Anxiety8703]

What I am getting at is that when you ask the patient's permission before placing the injection, you acknowledge their agency in the decision-making surrounding their own health care and cultivate a doctor-patient relationship founded on a sense of mutual trust and partnership rather than paternalism.

Just seems like common sense to me. I always involve my patients in the decision making process. I think some people have an ego complex and look down on their patients instead of treating them like human beings. I tell them what I recommend but if they are hesitant I tell them it’s all good I’m not going to force you do anything and you can think about it. When they realize I’m right and know delaying something for a a few weeks is pointless they usually cave

 

[Weirdy]

Truth to both sides.

Some patients don't know what they want. Are coming to you for answers and want an answer spoon fed to them because they simply do not know what treatment they need based on how they are doing at the moment. They will give you 100% decision making process and agree with it.

Some will weigh options and will not pick or give you push back unless you present them with options.

Some don't want anything even after you've spent 20minutes answering every question in detail and more.

Up to you to read your patient, see which profile they fit, and do what medically benefits them.

 

[ExperiencedDPM]

A few thoughts:

1) choose your surgical patient wisely. If you get that “feeling”, trust your gut instinct and move on to the next patient.

2) never talk a patient into surgery.

3) use videos or I prefer drawings to explain to the patient you are “surgically breaking” their bone. They don’t understand osteotomy or realign.

4). If a patient keeps asking about pain control during a pre op visit, please re-read # 1 above.

5) don’t try to be the hero and think you can fix another surgeon’s train wreck.

6) if a patient even remotely hints at suing a prior provider, please see # 1 again.

7) never criticize a prior provider’s shoddy work. Just focus on correcting the problem

8) make your first few cases simple and straight forward. You can only make one first impression with the OR staff.

9) arrive at the OR much prior to your case so no one is waiting for you and to make sure all pre op labs are available, hardware is available, etc. Do NOT walk in late.

10) be efficient in the OR and respect the staff. Don’t play the “doctor” card with them, you’ll look like a jack ass. They won’t be impressed.

11) Anesthesia will despise you if you take 2 hours to do a 30 min case.

12) don’t blame anything on the equipment or lack of equipment.

13) don’t go through 9 screws and 3 plates until you find the one that works. The OR committee will meet with you if that happens.

14) ALWAYS speak with your patient in recovery and don’t run out of the facility. It’s reassurance.

15) ALWAYS find the family and let them know all went well and how to get in touch with you if needed.

16) create your own post op instructions and include do’s AND don’ts. (Don’t change your dressing is numero uno)

17 be available vis cell or service if the patient calls. Do not make them wait for a call back

18) I make it a practice of calling every surgical patient that night to answer questions and check on them. It’s a way to reinforce the post op instructions and lets them know you care about them.

19) I treat my surgical patients like gold. They trusted me to perform their surgery and I take that seriously. That alone can keep you out of lawsuits.

20) be 100% honest post op if there are any funky X-ray changes or something is wrong. Don’t sugar coat or bury it.

21) bill honestly and ethically.

22) always thank the OR staff. Always.

23) don’t wear your scrubs to your kid’s back to school night. You’ll look like a douche.

 

[Hybrocure]

A few thoughts:

1) choose your surgical patient wisely. If you get that “feeling”, trust your gut instinct and move on to the next patient.

2) never talk a patient into surgery.

3) use videos or I prefer drawings to explain to the patient you are “surgically breaking” their bone. They don’t understand osteotomy or realign.

4). If a patient keeps asking about pain control during a pre op visit, please re-read # 1 above.

5) don’t try to be the hero and think you can fix another surgeon’s train wreck.

6) if a patient even remotely hints at suing a prior provider, please see # 1 again.

7) never criticize a prior provider’s shoddy work. Just focus on correcting the problem

8) make your first few cases simple and straight forward. You can only make one first impression with the OR staff.

9) arrive at the OR much prior to your case so no one is waiting for you and to make sure all pre op labs are available, hardware is available, etc. Do NOT walk in late.

10) be efficient in the OR and respect the staff. Don’t play the “doctor” card with them, you’ll look like a jack ass. They won’t be impressed.

11) Anesthesia will despise you if you take 2 hours to do a 30 min case.

12) don’t blame anything on the equipment or lack of equipment.

13) don’t go through 9 screws and 3 plates until you find the one that works. The OR committee will meet with you if that happens.

14) ALWAYS speak with your patient in recovery and don’t run out of the facility. It’s reassurance.

15) ALWAYS find the family and let them know all went well and how to get in touch with you if needed.

16) create your own post op instructions and include do’s AND don’ts. (Don’t change your dressing is numero uno)

17 be available vis cell or service if the patient calls. Do not make them wait for a call back

18) I make it a practice of calling every surgical patient that night to answer questions and check on them. It’s a way to reinforce the post op instructions and lets them know you care about them.

19) I treat my surgical patients like gold. They trusted me to perform their surgery and I take that seriously. That alone can keep you out of lawsuits.

20) be 100% honest post op if there are any funky X-ray changes or something is wrong. Don’t sugar coat or bury it.

21) bill honestly and ethically.

22) always thank the OR staff. Always.

23) don’t wear your scrubs to your kid’s back to school night. You’ll look like a douche.

Based. Every point is spot on on how to be a likeable doctor. Everything you mention is basically how I practice.

It only takes a couple months out from residency to realize not to judge other doctors work because we all have complications. This is about being able to read a person/patient and isn’t something that can be taught. When I have a patient come in who has had 5 other docs operate on them and wasn’t satisfied it’s pretty important you realize the problem is not the prior docs

 

[heybrother]

1) Do the surgery you believe is right. I've had good outcomes adjusting plans and compromising, but I've had more regrets. Nothing is more meh then the patient leaving to go elsewhere and have the surgery you wanted them to have to begin with.

2) Surprises in the post-op period are often questions that you didn't ask in the pre-op. "What was the post-op like for your last surgery"

3) Cases are ideally done on problems that you understand the root cause of well. If you find yourself thinking - "I don't really understand why this is happening" don't do the case.

4) There is no surgery that pays so well that if it goes disastrously it will have been worth it. You are not some famous last ditch heart surgeon where the patient is going to die anyway unless you operate. The vast majority of surgeries are poorly reimbursed. "I must do this bunion, even though I don't want to, so my family can eat" is not a thing.

5) Recognize when a patient is truly telling/showing you they've exhausted conservative therapy already ie. listen, but recognize the value of putting the patient through some sort conservative therapy so you can get to know them. "I would like to get to know you better."

6) Patient's who refuse PT are often problematic. If they can't do PT before surgery, they probably won't want to do it after when they need it.

7) Do cases the way you know how to do them - especially in the beginning. If the facts of the case don't fit your skill-set (which will expand and evolve) don't do the case.

8) When you tell someone - I can't do your case - and you know you can't - stick to your guns. Patients appreciate doctors who care - for example, you explained how complicated the case is and why you don't feel comfortable doing it. This may actually make the patient more comfortable with you and they may then try that much harder to convince you to do the case. No means no lady.

9) Do not operate on people who scream at your staff. There's a well done discussion about this somewhere else on SDN about recognizing how stress and fear can impact patients who may be having the worst day of their life ie. patients being rude in the emergency room. That's not the same thing as a patient who screams at your surgical scheduler for their bunion.

10) The OR staff scrub with everyone. They will know if you suck. They absolutely talk about doctors. Have a reasonable understanding of where you fit in the world. If there's no one else in your area who can do a triple and you are a little slow, but have good outcomes - fine. Warn the OR it will be a long case. Plan your schedule accordingly. If Dr. PerfectTriple in town does 5-6 ankle fusions/triples a week and you do 2 a year you need to ask yourself whether you really need to continue to do 5 hour triples. Maybe you are great at them or maybe you should change jobs to somewhere that you get more rearfoot referrals. But do not do cases just so you can get rearfoot board certified. "I do 2-3 rearfoot fusions a year so in 5 years I'll have my rearfoot numbers and get certified" is not a thing. The rearfoot pass rates clearly show that very few people are getting rearfoot certified and its likely due to case volume.

11) Almost any single joint case can be done in under an hour. If you are sitting there spending 3 hours on every case - reevaluate.

12) An MSK problem like an arthritic joint with indescribable, untouchable nerve pain is a trip to Hell waiting for you in the post-op. "I don't want an injection, I want surgery". Danger. Danger.

13) Don't always assume the worst about your colleagues/other doctors. Yes, you'll see ridiculous things, but the patient who told you their 1st doctor never told them anything will be the patient who doesn't listen to a word you say.

14) Ask your nurse/staff what they thought of a patient. The other day my nurse told me an oddly behaving patient was an alcoholic. It was not in the paperwork, but it explained a lot.

15) You might be surprised to find that life can be pretty good just doing injections, nail surgery, flexor tenotomies, and straight forward forefoot surgeries.

EDIT:
16) Don't do cases because someone else told the patient you would. My partner once referred me a strange patient and told them I would operate. I will skip all the details, the red flags were there, and just tell you the story ends with the patient crashing their car into my office building. No one as hurt.

 

[Feli]

I would add one more thought to this topic:

Realize the difference (and sizable skill gap) between basic low and higher energy trauma.
Low energy trauma like SER2, met fx, etc and high energy trauma a la crush, MVA, open, displaced, comminuted, etc.
Know what can be fixed and what just hardly ever turns out well even if Roy Sanders or a Swiss AO team is ORIF-ing it. Prep people for that.
This is really just a communication thing, but it's highly important.

This would be your (higher energy) intra-articular calc fx, pilon fx, Lisfranc fx, and Achilles ruptures.
I routinely use the term "life changing injury" on any of those.
Some of your bimall and bimall equivalent and trimall can fall in this boat, but they can sometimes do pretty well.
The major intra-articular fx and Achilles are always bad news bears.
The pts are lucky to ever have full or near-full ROM, near-full strength, etc again. It's unlikely.
Gumann, who literally wrote the book on this stuff, said it well at an ACFAS ASC meeting that these have "about 800% chance of arthritis."

The down time and rehab time is quite substantial and ongoing. Again... life- changing- injuries.
The person usually will be limited on shoes, sports, and other stuff afterwards with these injuries. This must be spelled out plainly.
Subsequent surgery for HWR, scope, fusion are obviously not uncommon. They need to be informed.
Note that you are getting into major surgery on someone who is typically stressed out and basically unknown to you (compliance? health? medical-legal?).
I do bi-valve cast in OR (and re-use it for the first 2-3wks) on basically all of these... splint or CAM boot early is really rolling the dice.
Infections and wound issues and long term swelling or numb areas are common (hopefully not chronic pain, but it's possible).

Personally, I operate on Achilles ruptures in nearly any reasonably active person. Debate if you want, but I think it's basically malpractice not to these days with how good the repairs are and how much quicker they can start rehab with op vs non-op.
I also ORIF nearly every intra-artic calc fx decent candidate (don't trust Achilles pull, faster rehab, some ORIF work well awhile, it makes later fusion/recon easier).
Conversely, I barely ever ORIF non-displaced Lisfrancs (it basically forces them to at least 3 surgeries: ORIF, HWR, fusion... possibly more. I usually fuse displaced Lisfranc primarily. Frankly, they turn out pretty bad and painful and gait is changed no matter what you do - surgery or not. Lisfranc is a mean old lady.
Unstable ankle fx and pilons are obvious ORIF unless the pt is a drug addict or PVD or otherwise train wreck.

It's also important to know your (and your facility/OR/team) limits and do not be afraid to refer. Fwiw, my volume on this stuff is nowhere near what some ppl's is, but I had fairly extensive training and early career exp in major metro and have since worked at rural or small town hospitals with little/no ortho... so mainly just wanted to underscore the communication with ER/trauma pt expectations part.
Likewise, don't be afraid to primarily amp crush/mangle stuff... it's a case-by-case, but most of it just gets infected and osteomyelitis if you try to pin + abx it... and you'll need to amp it anyways. It's much better psychologically for most ppl to just have digit amp or TMA or whatever if facing open fx with serious crush.

Diabetic/wound stuff is the easiest we do because nobody cares... and it's technically easy also. Very hard to "fail" on pus bus.
Elective is sometimes easy and sometimes hard... but ppl's eyes are always on the results (pt, PCPs, OR, etc). Expectations are high.
Trauma pts just want to walk again, but the surgery is often technically hard... and communication is also important.

I have seen more than a few this year where I think the communication was really blown. It can happen both ways: doc tells trauma pt they need surgery when it should just be a boot (minimally/non-displaced fx, most 5th met fx, terrible surgical candidate with low activity baseline, etc), and also other situations where doc tells the pt they will get them fixed right up (yet pt is in a load of hurt with a real bad injury and really needs to know to temper expectations and expect very long and never-100% recovery). 🙂

 

[Homo sapien]

I would add one more thought to this topic:

Realize the difference (and sizable skill gap) between basic low and higher energy trauma.
Low energy trauma like SER2, met fx, etc and high energy trauma a la crush, MVA, open, displaced, comminuted, etc.
Know what can be fixed and what just hardly ever turns out well even if Roy Sanders or a Swiss AO team is ORIF-ing it. Prep people for that.
This is really just a communication thing, but it's highly important.

This would be your (higher energy) intra-articular calc fx, pilon fx, Lisfranc fx, and Achilles ruptures.
I routinely use the term "life changing injury" on any of those.
Some of your bimall and bimall equivalent and trimall can fall in this boat, but they can sometimes do pretty well.
The major intra-articular fx and Achilles are always bad news bears.
The pts are lucky to ever have full or near-full ROM, near-full strength, etc again. It's unlikely.
Gumann, who literally wrote the book on this stuff, said it well at an ACFAS ASC meeting that these have "about 800% chance of arthritis."

The down time and rehab time is quite substantial and ongoing. Again... life- changing- injuries.
The person usually will be limited on shoes, sports, and other stuff afterwards with these injuries. This must be spelled out plainly.
Subsequent surgery for HWR, scope, fusion are obviously not uncommon. They need to be informed.
Note that you are getting into major surgery on someone who is typically stressed out and basically unknown to you (compliance? health? medical-legal?).
I do bi-valve cast in OR (and re-use it for the first 2-3wks) on basically all of these... splint or CAM boot early is really rolling the dice.
Infections and wound issues and long term swelling or numb areas are common (hopefully not chronic pain, but it's possible).

Personally, I operate on Achilles ruptures in nearly any reasonably active person. Debate if you want, but I think it's basically malpractice not to these days with how good the repairs are and how much quicker they can start rehab with op vs non-op.
I also ORIF nearly every intra-artic calc fx decent candidate (don't trust Achilles pull, faster rehab, some ORIF work well awhile, it makes later fusion/recon easier).
Conversely, I barely ever ORIF non-displaced Lisfrancs (it basically forces them to at least 3 surgeries: ORIF, HWR, fusion... possibly more. I usually fuse displaced Lisfranc primarily. Frankly, they turn out pretty bad and painful and gait is changed no matter what you do - surgery or not. Lisfranc is a mean old lady.
Unstable ankle fx and pilons are obvious ORIF unless the pt is a drug addict or PVD or otherwise train wreck.

It's also important to know your (and your facility/OR/team) limits and do not be afraid to refer. Fwiw, my volume on this stuff is nowhere near what some ppl's is, but I had fairly extensive training and early career exp in major metro and have since worked at rural or small town hospitals with little/no ortho... so mainly just wanted to underscore the communication with ER/trauma pt expectations part.
Likewise, don't be afraid to primarily amp crush/mangle stuff... it's a case-by-case, but most of it just gets infected and osteomyelitis if you try to pin + abx it... and you'll need to amp it anyways. It's much better psychologically for most ppl to just have digit amp or TMA or whatever if facing open fx with serious crush.

Diabetic/wound stuff is the easiest we do because nobody cares... and it's technically easy also. Very hard to "fail" on pus bus.
Elective is sometimes easy and sometimes hard... but ppl's eyes are always on the results (pt, PCPs, OR, etc). Expectations are high.
Trauma pts just want to walk again, but the surgery is often technically hard... and communication is also important.

I have seen more than a few this year where I think the communication was really blown. It can happen both ways: doc tells trauma pt they need surgery when it should just be a boot (minimally/non-displaced fx, most 5th met fx, terrible surgical candidate with low activity baseline, etc), and also other situations where doc tells the pt they will get them fixed right up (yet pt is in a load of hurt with a real bad injury and really needs to know to temper expectations and expect very long and never-100% recovery). 🙂

In my past 3 years as an independent I've come to realize patient expectations are so important. They need an accurate benchmark of what their life will be post injury.

 

[MicroPod]

What tips do you all have for operating without someone else there to assist other than the scrub tech?

 

[AttackNME]

What tips do you all have for operating without someone else there to assist other than the scrub tech?

Biggest thing I found helpful was learning to insert pins, then reduce and hold position, and then let the tech advance the wire. made a world of difference once I got good at that

 

[Adam Smasher]

What tips do you all have for operating without someone else there to assist other than the scrub tech?

 

[josebiwasabi]

Use the stapler to perform no-touch technique skin retraction

 

[GreenHousePub]

Biggest thing I found helpful was learning to insert pins, then reduce and hold position, and then let the tech advance the wire. made a world of difference once I got good at that

Be careful doing this, our hospital will not let anyone beside the operating surgeon do any meaningful parts in surgery.

 

[air bud]

Biggest thing I found helpful was learning to insert pins, then reduce and hold position, and then let the tech advance the wire. made a world of difference once I got good at that

Lapiplasty fixes this.

 

[PMG03470]

Biggest thing I found helpful was learning to insert pins, then reduce and hold position, and then let the tech advance the wire. made a world of difference once I got good at that

My techs cannot and will not do this. Agree to the pins for retracting though. I have had to start using Lapifuse system since I don’t get the assistance I need to retract skin hold correction and drive screws

 

[wakaflocka88]

My techs cannot and will not do this. Agree to the pins for retracting though. I have had to start using Lapifuse system since I don’t get the assistance I need to retract skin hold correction and drive screws

Weber clamp, weitlaner and some 4-0 nylon to hold skin out of the way is all you need. Minimizing skin retraction has made wound dehiscence rates rare/non existent. No tourniquet either. Try it

 

[Retrograde_Nail]

Just do MIS bunions. It will change your life.

 

[dtrack22]

Just do MIS bunions. It will change your life.

And ABFAS reviewers will fail you for it. Thank god those clowns have no bearing on my life or practice…

But yes, percutaneous distal met osteotomies with mega correction are fantastic procedures.

 

[Flip-flop-flerpity]

ABFAS picked 3 MIS bunion cases (with hardware of course) for my foot cert and I passed. I know they say they don't accept MIS surgery but my thought are they mean they don't accept stick a burr in there and let it float cases like I've seen some guys in my area do

 

[shadesofgrey]

I also passed my ABFAS cert with multiple MIS bunions. However, I still stand by my criticism of the process, which as stated before is a ****show that is directly harmful to young docs.

Ps mods don’t lock this post for being off subject, it’s an Internet forum, diversion is expectant!

 

[Weirdy]

Pretty on topic. Every graduating resident has to deal with board certification. Nothing wrong here.

 

[MicroPod]

Would any attendings be willing to list the modifiers commonly used in podiatry and when it is appropriate to use them? I found some general info by searching online but it would be nice to hear examples/scenarios of commonly used modifiers in podiatry.

 

[PMG03470]

Would any attendings be willing to list the modifiers commonly used in podiatry and when it is appropriate to use them? I found some general info by searching online but it would be nice to hear examples/scenarios of commonly used modifiers in podiatry.

-25 when OV with a procedure
-24 when OV in global period for unrelated problem
-79 when procedure during global period for unrelated problem.

These are the 3 most commonly used for me personally.

 

[Feli]

-25 and -59 are most common.
They are all listed on APMA Coding RC (good subscription for any PP type) or many other places for free. Sent you PM.
Podiatry uses 25 24 59 50 58 76 77 79, LT/RT, Tx mods, etc.

If you work for a hospital - particularly a govt hospital or govt-money hospital (almost sure you do), you don't have to worry a ton about it. They will find a way to screw up billing even if you give them perfect CPTs and modifiers on your clinic and operative notes... and they'll still require 4 different clipboard consents for things that don't need consents (ingrowns, injects, wounds, maybe even calluses or nail trimming, etc) regardless of what logic says. Actual revenue earned from pt care is not very essential for them as they get a govt money dump truck every week regardless. 🙂

 

[Adam Smasher]

24 is the best modifier, I use it to get all my postop visits paid

 

[air bud]

Would any attendings be willing to list the modifiers commonly used in podiatry and when it is appropriate to use them? I found some general info by searching online but it would be nice to hear examples/scenarios of commonly used modifiers in podiatry.

Go to a coding course. Be more concerned with codes than modifiers. But also those.

 

[air bud]

24 is the best modifier, I use it to get all my postop visits paid

I am laughing but I don't know what a 24 modifier is

Insert anchorman brick tamland gif

 

[mandrew]

I am a 3rd year resident starting my first attending job in late July. I feel pretty comfortable overall in clinic and decision making. I’m still feel nervous about operating by myself. I do alright in the OR but it’s always been with an attending present. Also I think it will take awhile to get cases so I am sure I’ll feel rusty by the time I start operating.

I guess I’m just hoping to get any good advice and/or encouragement for those of us graduating and starting to practice soon.

So how are things going so far?

 

[MicroPod]

Started about 3 weeks ago. There is another podiatrist who works in the same system so it’s been nice to have them as a mentor of sorts. Additionally I have been going to all of his cases till I get busier and they usually leave after a couple of minutes into the case. Have had around 10-12 in the past couple of weeks. So far only have had pus or osteo cases (Native American population) which I feel like there is less pressure most of the time. I think the best thing has been not having to try and predict what the attending wants to do for the patient (many times financially motivated unfortunately). Overall going well though and I feel pretty confident in the OR because you realize you are the expert.

 

[podiatryresident]

Hi. May I ask if someone has experience working for a HMO group ? I may sign a contract with a small HMO group that has a lot of PCPs, 2 urgent care centers, no hospital, not many other specialties. They've already had a old podiatrist who doesn't do much, they usually refer out a lot of patients.
From my understanding, they won't expect me to do a lot of electives but they're ok if I need to do necessary procedures . The offer is approximate 200k including 15k signing bonus for first year and re-discuss about bonus structures after 1 year, location is good and I'm a 3rd year at the average program. Thank you so much!

 

[HardRoadPaved]

they won't expect me to do a lot of electives

Nor will you want to if you get your money up front. You just tell them to massage their bunions with voltaren, make sure they really went out and bought a pair of Hokas and inserts. Otherwise you tell the patient the HMO wont approve surgery since they havent exhausted conservative care.

The offer is approximate 200k including 15k signing bonus for first year and re-discuss about bonus structures after 1 year, location is good and I'm a 3rd year at the average program. Thank you so much!

How many patients are you capturing? What is the current podiatry utilization percentage (one in how many see a podiatrist)? I hope location is good = affluent area so you can make money on ancillaries and not rely on just your hmo contract.

 

[air bud]

Nor will you want to if you get your money up front. You just tell them to massage their bunions with voltaren, make sure they really went out and bought a pair of Hokas and inserts. Otherwise you tell the patient the HMO wont approve surgery since they havent exhausted conservative care.

How many patients are you capturing? What is the current podiatry utilization percentage (one in how many see a podiatrist)? I hope location is good = affluent area so you can make money on ancillaries and not rely on just your hmo contract.

Ancillaries....this is employed. You and your lotions and potions and lasers and custom orthotics...

 

[HardRoadPaved]

Ancillaries....this is employed. You and your lotions and potions and lasers and custom orthotics...

Its a two sided sword. You want to get cases when you first get out to get boarded. However if it's just a bunch of captitated patients you might get a lot of push back if you're spending a lot. On the flip side 200k to veg out isn't something awful for a first job

 

[Feli]

Its a two sided sword. You want to get cases when you first get out to get boarded. However if it's just a bunch of captitated patients you might get a lot of push back if you're spending a lot. On the flip side 200k to veg out isn't something awful for a first job

Yep, hmo or supergroup or msg or VA or basically whatever for 200k doing 4-5 days/wk is a potentially fine first pod job. Doubly fine if you can do, or prep to do, solo nearby after a few years (or even start/do it concurrent on the DL).

200k jobs with fair hours aren't super abundant for DPMs. Too bad.

 

[GreenHousePub]

Hi. May I ask if someone has experience working for a HMO group ? I may sign a contract with a small HMO group that has a lot of PCPs, 2 urgent care centers, no hospital, not many other specialties. They've already had a old podiatrist who doesn't do much, they usually refer out a lot of patients.
From my understanding, they won't expect me to do a lot of electives but they're ok if I need to do necessary procedures . The offer is approximate 200k including 15k signing bonus for first year and re-discuss about bonus structures after 1 year, location is good and I'm a 3rd year at the average program. Thank you so much!

Take it, could be a decent job.